the importance of early orthodontic evaluation€¦ · but the field of orthodontics has changed...

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chapter twoTHE IMPORTANCE OF EARLY ORTHODONTIC EVALUATION

I had a new patient a few weeks ago who had been referred to me

by her family dentist. She was young, only seven years old, so my

first interaction was with her mom. After we greeted each other,

the child’s mom blurted out, “She is only seven years old! Why did

our dentist refer her for an evaluation at seven? This seems way too

young. She’s only lost four baby teeth so far. I only got braces when

I was fifteen—after I had lost all of my baby teeth. Please explain to

me the reason for this evaluation.”

—DR. VERBIC

I hear reactions and questions like this quite a bit when I explain the importance of an orthodontic consult by the time a child is seven years old. I always respond with a version of the following: “You’d be surprised by all the problems I see in teenagers we could have helped prevent from happening if they had just visited me a few years prior.

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I could have saved them from needing invasive surgery and I could have saved them thousands of dollars.”

Timing is everything when it comes to orthodontic treatment in children. Seven years old seems young, and to be fair, it is very different advice compared to what was given just a decade or so ago. The timeline for orthodontic evaluation used to be scheduled for when all the baby teeth were gone and all of the adult teeth were in. But the field of orthodontics has changed dramatically based on new research and treatment options.

RECOGNITION OF ORTHODONTIC PROBLEMS THAT CAN BE TREATED EARLYMany orthodontic problems that can be corrected easily during childhood cannot be corrected without more-invasive treatment, such as surgery, if the problems are left untreated past puberty and into adulthood. This is because when the jaw bones are still growing, orthodontists have some ability to control the magnitude and direction of their growth. After most growth has stopped, following puberty, patients with abnormal jaw growth may be left only with the choice of surgical correction or compromised results. The American Association of Orthodontists (AAO) recommends children have an orthodontic evaluation at the age of seven.6 This is because at age seven it is possible to both determine if there are any abnormalities in jaw growth and it is possible to intervene with orthopedic correction, if needed. The AAO also provides a list of the common orthodontic problems in younger children that require orthodontic referral and potential phase 1 treatment. The following listed problems are illus-trated in Figure 2.1. It also lists other issues to look for in your child,

6 “Frequently Asked Questions,” American Association of Orthodontists, www.aaoinfo.org/frequently-asked-questions

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including speech difficulties, thumb sucking, mouth breathing, and so on, which indicate that an evaluation by an orthodontist is important:

• Anterior Crossbite

• Posterior Crossbite

• Crowding

• Open bite

• Protrusion

• Deep bite

• Underbite

• Spacing Issues

Anna K. was referred to me by her family dentist because her top

canine tooth had fallen out at age thirty. At her first appointment,

we used special x-ray techniques to find out what was going on. It

turned out Anna had an impacted adult top canine tooth; the tooth

that had fallen out was a baby tooth. And we saw she also had an

impacted adult tooth on the bottom. So, the only treatment plan

available was to pull the other baby tooth and perform a minor

surgery to place two special bands within the gum on the impacted

adult teeth to help pull them into the mouth. The patient also needed

braces for quite a while. If this patient had been evaluated by an

orthodontist when she was eight years old, the fact that her adult

teeth were moving in the wrong direction would have been seen

right away and treatment could have been started. If the baby teeth

had been pulled earlier, there would have been much better odds

that the teeth would have come in straight on their own.

—DR. VERBIC


Figure 2 .1


DON’T WAIT FOR A REFERRAL Many parents rely on their family dentist to tell them when it is time to bring their children in for an orthodontic evaluation. This isn’t always a wise strategy, however, because most dentists receive little if any training to identify orthodontic and orthopedic problems in growing children. Most dental offices don’t even have the panoramic and cephalometric x-ray equipment needed to identify the many problems that can be prevented or corrected early on, such as impacted or missing teeth.

Every orthodontist I know has a story like the one above, and this is only one story in the many, many cases of patients who have come to me in adulthood with issues that could have been prevented or treated much earlier. If these patients had been referred earlier by their dentist, these problems may have prevented the impaction of adult teeth, or they would have been able to have space maintainers placed for missing teeth that would have saved them thousands of dollars and reduced their time in braces by up to a year. The good news is that you don’t need a referral from your family dentist to see an orthodontist. If your child needs orthodontic treatment at an early age, and you have insurance coverage, in almost all instances insurance will cover a large portion of your child’s treatment.

NEED FOR EARLY TREATMENTTake a look back at Figure 2.1 which shows examples of orthodon-tic problems that should be evaluated, and possibly corrected, at a younger age. If children have one of these problems, early treatment may be necessary. If the orthodontist identifies that the problem should be corrected as early as possible, they will suggest what ortho-dontists commonly call a “first phase” of treatment. It is called a first phase of treatment because a “second phase” is always needed to


straighten the remaining adult teeth that erupt into the mouth, and to correct how the top and bottom teeth bite together. Yes, it is true that when treatment needs to be broken up into two phases like this, it is often considerably more expensive than when treatment can be completed with just one phase of treatment. However, if the child does not receive treatment for a developing problem in a first phase, the cost of treating all the issues after the adult teeth have come in could be not only more expensive, but also take a much longer time and involve surgery, which adds considerably to the overall cost of treatment. With all the above being said, only about 10 percent of children have the types of orthodontic problems that should be corrected at a younger age before all of the adult teeth have come in.7

Parents will sometimes ask why braces can’t just be added to the adult teeth that come into the mouth as treatment progresses so only one phase of treatment is needed. This is a bad idea because the braces would then need to remain on the teeth for four to five years while waiting for all of the adult teeth to erupt. Leaving braces on the teeth for this long wouldn’t be healthy for the teeth because braces are difficult to brush and floss around. It would also substantially increase the number of visits to the orthodontic office to maintain the braces for this long. And anyone who has ever worn braces can tell you that under no circumstances would they want to wear them for that long. Because they are uncomfortable and a nuisance, our goal as orthodontists is to get the best result for our patients while minimizing how long patients are in braces. To achieve this, it is sometimes necessary to stage treatment in two phases. Orthodontists can complete treatment at one time after all of the adult teeth have

7 Anthony A. Gianelly, “One-phase versus two-phase treatment,” American Journal of Orthodontics & Dentofacial Orthopedics 108, no. 5 (1995): 556–559, https://doi.org/10.1016/S0889-5406(95)70057-9


come in as long as there aren’t problems that require a first phase of treatment. The good news—this is possible for 90 percent of children.8

UNSCRUPULOUS PRACTITIONERSA concern many parents might have when an orthodontist suggests phase-one treatment for their child is that two phases of treatment may not really be needed and some orthodontists suggest it to most, if not all, of their young patients just to line their pockets with more money. While it is true there are unscrupulous practitioners out there doing this sort of thing, it is obviously not a sustainable way to run an orthodontic practice. Eventually, word would get out that this is going on, and the orthodontic practice would fail due to a lack of patients. Trust is the most important thing in running any business, whether it be an auto repair shop or an orthodontic practice. Verify that your orthodontic practice is certified and practicing orthodon-tics using the best practice measures by making sure the orthodontist is a member of the American Association of Orthodontists (AAO).

Membership in the AAO signifies the orthodontist has completed four years of dental school and at least two years of residency in a verified residency program.9 Also, social media and word of mouth recommendations are useful. If most patients at an orthodontic practice are happy with their results and feel like they got prime value for money spent, this is a good sign the orthodontic practice is honest and treating each patient individually using best practices.

8 Ibid.

9 Ibid.


RECOGNITION OF HOW ORTHODONTIC PROBLEMS CAN NEGATIVELY IMPACT CHILDRENIf you still are not convinced of the importance of taking your child for an orthodontic consult by age seven, think about the impact that orthodontic issues can have on children and why it is much better to intervene and prevent or treat problems early to avoid bigger problems later. There are three major areas where orthodontic problems can really impact children—speech, health of the teeth and jaws, and self-esteem.

Speech ProblemsPerhaps you may not automatically link speech problems with orth-odontic issues. However, orthodontic issues—in particular, maloc-clusions (which is a fancy word for saying that the teeth are not posi-tioned well when the mouth is closed)—can have a strong, negative impact on a child’s speech. Teeth positioning plays a critical role in a person’s ability to produce sounds, in particular the strident sounds like t, s, z, f, v, sh, ch, j, and zh. Strident sounds are ones produced with a strong noise; air is forced against the teeth and other parts of the mouth and tongue to produce the sounds. When teeth are not correctly positioned, these sounds are much more difficult to produce, leading to speech problems. In fact, various studies have shown that up to 60 percent of all speech disorders may be caused by malocclusion—and the more severe the malocclusion, the more severe the speech disorder.10

10 K. M. Leavy, G. J. Cisneros, and E. M. LeBlanc, “Malocclusion and Its Relation-ship to Speech, Sound Production: Redefining the Effect of Malocclusal Traits on Sounds Production,” Am J Orthod Dentofacial Orthop. 150, no. 1, (2016): 116–23, https://doi.org/10.1016/j.ajodo.2015.12.015


Health of the Teeth and JawsWhen it comes to the health of the teeth and jaws, early interven-tion is best. At the age of seven, many adult teeth are beginning to come into the mouth. This is the best time to correct any abnormali-ties that may be preventing the teeth from coming in, such as extra adult teeth, or baby teeth that aren’t falling out like they should. Any crossbites that may be occurring between the top and bottom teeth at this age should be identified and corrected as well to prevent gum recession and damage to the teeth themselves. Also, bad oral habits, such as thumb sucking, should be addressed at this age to prevent jaw growth abnormalities and malpositioning of the teeth. And finally, any breathing and airway problems—that can be caused by things like seasonal allergies and enlarged tonsils—adversely affecting how the jaws are growing should be identified and referred to an Ear, Nose, and Throat (ENT) doctor for evaluation and possible correction.

Self-Esteem As parents, we all want our children to grow up with a healthy self-esteem. It is important for children to feel confident in who they are and to feel confident in who they can become. As young children, they may not notice or care their teeth are crooked, but as they approach the teenage years, physical appearance may become more important and self-esteem issues may arise as teens navigate through the process of becoming adults. Problems with the appearance of the teeth can strongly affect a teenager’s self-esteem. In fact, studies have concluded that there is a strong association between a teenager’s unhappiness with how their teeth look and the development of low


self-esteem, and that this is particularly true for adolescent girls.11 There are even studies that show a link between malocclusions in children and adolescents and an increased risk of being bullied.12

The importance of problems with self-esteem should not be underestimated, especially in children. Many of these issues may escalate if ignored, leading to depression or even suicide. Nowadays, these problems are exacerbated by the presence of social media, because children can’t even escape the bullying they are experiencing at school while at home. It follows them through apps like Facebook, Instagram, and Snapchat. Having teeth with many issues can plague a child’s life when it comes to social media—it’s very hard to escape embarrassment or shame when camera phones can post a picture online in seconds.

The worst part is, sometimes kids don’t want to tell their parents about the bullying either. Maybe it’s too embarrassing, or they don’t actually want their parents to worry about them too much. So, they end up keeping it bottled up inside. When I was young, I had bad acne and didn’t want to talk to my parents about how it was affecting me because I was embarrassed. One day, my dad finally took me to the dermatologist, and I’m glad he did as I was able to dramatically improve my skin. I probably would’ve just continued to suffer with that problem and let it damage me emotionally if he had not intervened.

11 M. H. Jung, “Evaluation of the Effects of Malocclusion and Orthodontic Treatment on Self-Esteem in an Adolescent Population,” Am J Orthod Dentofacial Orthop. 138, no. 2 (2010): 160-166, https://doi.org/10.1016/j.ajodo.2008.08.040; D. Dhanani and Y. Kaul, “Dental Disorders Impact and Influence on Self-Esteem Levels Among Teenagers,” International Journal of Dental Research and Oral Sciences 2, no. 1 (2017), https://actascientifica.com/IJDROS/pdf/IJDROS-02-0010.pdf

12 J. Seehra, J. T. Newton and A. T. DiBiase, “Bullying in Schoolchildren – Its Relationship to Dental Appearance and Psychosocial Implications: An Update for GDPs,” British Dental Journal 210 (2011): 411–15, https://doi.org/10.1038/sj.bdj.2011.339


As an orthodontist, I am primarily concerned with the physical health of my patient’s teeth, jaw, and bite. However, having repeat-edly witnessed fi rsthand the emotional eff ects associated with having poor looking teeth, I know that treating patients’ teeth and creating a beautiful smile is just as important for my patients’ emotional health as it is for their physical health.

What I remember about my

childhood is that I was always

bullied for my smile; kids called

me a horse. I was small with a

small face and big teeth; too

many teeth for my mouth. I was always ashamed to smile and had no

confi dence. I wasn’t a good student. I couldn’t or didn’t want to answer

questions and was ashamed to talk. So, I didn’t do well in school at all.

As I grew older and into my teen years, I knew I really wanted braces

to fi x my teeth; it was a dream. But, I had to pay for everything out of

pocket myself. Neither I, nor my family, had dental insurance. So, I worked

hard and saved money and when I turned nineteen, I fi nally decided to go

for it. I found a dental clinic with an orthodontist I could walk to from my

parents’ home; it just happened to be Dr. Verbic’s offi ce. The moment I sat

down in the chair, I knew I was in the right place.

Dr. Verbic told me he could defi nitely give me the smile I wanted, but

he strongly suggested that I have four teeth removed . . . four premolars.

I trusted him and his knowledge and expertise. But the added cost of

removing teeth meant I had to work even harder in order to pay for

treatment. I had to trust him that it would be worth it. Dr. Verbic referred

me to an oral surgeon and I went for a consultation.

The oral surgeon asked, “Are you sure you want to remove these teeth?

You can’t get them back.”


I told him I was extremely confident in Dr. Verbic’s recommendation.

The four teeth were removed and the recovery was very simple. In fact,

only about a week later, I was in Dr. Verbic’s office getting my braces

on. I wore these braces for two years and I was a model patient. I was

not messing around. I wore my rubber bands as instructed and finished

treatment earlier than expected.

From the very moment my treatment started, there were big changes

in me and in my life. The fact that I was finally fixing my smile gave me

confidence; it propelled me as a student. I started communicating and

participating in class. In fact, throughout the rest of my time in treatment

I got straight A’s in school, and I am about to graduate from college this

year. Getting treatment made a huge difference in my life—there are so

many things I can accomplish now. I’ve never felt so confident. Because of

my experience and the difference orthodontic treatment made in my life,

I decided to major in a predental program in college. When I graduate, I

really hope to go on to dental school. I want to be an orthodontist and make

a difference in other peoples’ lives.

Here is something funny: A few years after my treatment, my pre-

dental program required me to shadow a local orthodontist. Guess who I

chose? That’s right: Dr. Verbic. Now, I get the chance to watch as he treats

and interacts with patients. My dream is to help people in the same way

Dr. Verbic helped not only me, but so many other people. Orthodontic

treatment has really changed the trajectory of my life and, for that, I am so

grateful. It was worth every hard-earned penny. —WANDA N.

As you can see, there are many good reasons to seek an orthodon-tic evaluation for your child around the age of seven. These reasons range from evaluating orthodontic concerns to intervene early and avoid more invasive treatment later, to addressing self-esteem issues a child may be having due to teasing about the appearance of his or her teeth. Addressing these issues early is best for the child; just ask Mary, the patient I referred to earlier who lost a baby tooth at age thirty.

the importance of early orthodontic evaluation€¦ · but the field of orthodontics has changed...

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